Provider Demographics
NPI:1295174720
Name:TACKETT, WHITNEY JO (PA)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:JO
Last Name:TACKETT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST RM M53
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0298
Mailing Address - Country:US
Mailing Address - Phone:859-323-5908
Mailing Address - Fax:859-323-8056
Practice Address - Street 1:800 ROSE ST RM M53
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-9103
Practice Address - Country:US
Practice Address - Phone:859-323-5908
Practice Address - Fax:859-323-8056
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-18
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant